Expert: Ivan Goldberg, M.D. - 2/22/2007

Question
I am bipolar with symptoms of psychosis which don't seem to coincide with my mania or my depression. I've also suffered from severe headaches for 11 years, which have been increasing in frequency and severity. I also have fibromyalgia. My doctors seem to take my symptoms of pain less seriously once they learn I've been diagnosed as bipolar. My psychiatrist thinks that if I sleep enough I should not have fibromyalgia symptoms and that I don't need the meds I've been given for fibromyalgia. I'm completely frustrated by the serious lack of empathy my doctors seem to have for me. I feel as if they are only trying to push me out the door and away from them so that they do not have to deal with me. I don't know how to make them take me seriously. I'm in pain every day. I take every medication they tell me to (for bipolar and for fibromyalgia) on a regular basis. I go for walks when I have the energy, I use full spectrum lights in my home. I am doing all I can, but I'm still in pain and I have headaches a minimum of once a week, sometimes up to four times a week. I mean, of course, serious headaches, not the one that I have nearly every day, but am able to still complete my daily activities. I am COMPLETELY FRUSTRATED with my pain and my doctors' care (or lack thereof) and I don't know how to make anyone take me seriously. I've done my own research and tried many ways of continuing my daily activities without letting my pain win. I can't do it anymore, and I can't seem to find anyone who will take a bipolar patient seriously. Do you have any advice about how I can get them to take me seriously?

Answer
Hi Hilary . . .

People with bipolar disorder who have other health PROBLEMS are often not taken seriously, To get good care you will probably have to seek out care at a major medical school-associated medical center.

Below are some abstracts on the relationship between bipolar disorder and migraine and fibromyalgia.

Also you might want to do some reading about schizo-affective disorder and complex partial seizures.

Best regards . . .

Ivan
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1: J Clin Psychiatry. 2006 Aug;67(8):1219-25.    Related Articles, Links
   Click here to read
   Comorbidity of fibromyalgia and psychiatric disorders.

   Arnold LM, Hudson JI, Keck PE, Auchenbach MB, Javaras KN, Hess EV.

   Women's Health Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio 45219, USA. Lesley.Arnold@uc.edu

   OBJECTIVE: To assess the co-occurrence of fibromyalgia with psychiatric disorders in participants of a fibromyalgia family study. METHOD: Patients (probands) with fibromyalgia, control probands with rheumatoid arthritis, and first-degree relatives of both groups completed a structured clinical interview and tender point examination. The co-occurrence odds ratio (OR) (the odds of a lifetime comorbid DSM-IV disorder in an individual with fibromyalgia divided by the odds of a lifetime comorbid disorder in an individual without fibromyalgia, adjusted for age and sex) was calculated; observations were weighted by the inverse probability of selection, based on the fibromyalgia status of the pro-band; and standard errors were adjusted for the correlation of observations within families. The study was conducted from September 1999 to April 2002. RESULTS: We evaluated 78 fibromyalgia pro-bands and 146 of their relatives, and 40 rheumatoid arthritis probands and 72 of their relatives. Among the relatives of both proband groups, we identified 30 cases of fibromyalgia, bringing the total number of individuals with fibromyalgia to 108, compared with 228 without fibromyalgia. The co-occurrence ORs for specific disorders in individuals with versus those without fibromyalgia were as follows: bipolar disorder: 153 (95% CI = 26 to 902, p < .001); major depressive disorder: 2.7 (95% CI = 1.2 to 6.0, p = .013); any anxiety disorder: 6.7 (95% CI = 2.3 to 20, p < .001); any eating disorder: 2.4 (95% CI = 0.36 to 17, p = .36); and any substance use disorder: 3.3 (95% CI = 1.1 to 10, p = .040). CONCLUSIONS: There is substantial lifetime psychiatric comorbidity in individuals with fibromyalgia. These results have important clinical and theoretical implications, including the possibility that fibromyalgia might share underlying pathophysiologic links with some psychiatric disorders.

   Publication Types:

       * Comparative Study
       * Research Support, N.I.H., Extramural


   PMID: 16965199 [PubMed - indexed for MEDLINE]

2: J Am Med Womens Assoc. 2004 Spring;59(2):91-100.    Related Articles, Links
   Click here to read
   Women and bipolar disorder across the life span.

   Sit D.

   University of Pittsburgh, Western Psychiatric Institute and Clinic, USA.

   Bipolar I disorder occurs in approximately 1% of the adult population, and it affects women and men equally. Women develop bipolar II disorder, bipolar depression, mixed mania, and a rapid-cycling course of illness more commonly than men and are at greater risk of such comorbid conditions as alcohol use problems, thyroid disease, medication-induced obesity, and migraine headaches. The treatment of bipolar disorder remains challenging. Although lithium reduces symptoms and prevents recurrence with good efficacy, a significant number of patients stop taking it. Furthermore, several anticonvulsants and antidepressants are prescribed off label for acute episodes and prophylaxis despite the lack of adequate research support. Psychotherapy may alleviate mania or depression and improve treatment compliance, yet its ability to prevent relapse remains uncertain. Changes throughout the reproductive cycle also have an impact on the onset and presentation of bipolar symptoms and the choice of treatment. This article provides an overview of common presentations and comorbidities, along with approaches to evaluation and treatment of women with bipolar disorder.

   Publication Types:

       * Research Support, Non-U.S. Gov't
       * Review


   PMID: 15134424 [PubMed - indexed for MEDLINE]

3: J Affect Disord. 1999 Jan-Mar;52(1-3):239-41.    Related Articles, Links

   Prevalence of migraine in bipolar disorder.

   Mahmood T, Romans S, Silverstone T.

   Department of Psychological Medicine, University of Otago, Dunedin School of Medicine, New Zealand. tariq.mahmood@stonebow.otago.ac.nz

   BACKGROUND: This study was undertaken to estimate the prevalence of migraine in people suffering from bipolar affective disorder. METHODS: a headache questionnaire incorporating the newly introduced International Headache Society (IHS) criteria was given to 117 patients on the Dunedin Bipolar Research Register. RESULTS: a total of 81 (69%) completed the questionnaire, out of which 21 (25.9%) reported migraine headaches. 25% of bipolar men and 27% of bipolar women suffered from migraine. CONCLUSIONS: these rates are higher than those reported in the general population with the rate for bipolar men being almost five-times higher than expected. An increased risk of suffering form migraine was particularly noted in bipolar patients with an early onset of the disorder. This may represent a more severe form of bipolar affective disorder.

   PMID: 10357039 [PubMed - indexed for MEDLINE]

4: Psychopharmacol Bull. 1998;34(3):239-43.    Related Articles, Links

   Women with bipolar disorder: findings from the NIMH Genetics Initiative sample.

   Blehar MC, DePaulo JR Jr, Gershon ES, Reich T, Simpson SG, Nurnberger JI Jr.

   Division of Mental Disorders, Behavioral Research and AIDS, National Institute of Mental Health, Rockville, MD 20857, USA.

   Bipolar I (BPI) mood disorder is a severe recurrent mental Illness with a population prevalence of 1 percent. Evidence is strong for genetic risk factors in onset. However, unlike unipolar mood disorders, in which women outnumber men by 2 to 1, for BPI disorder, the male:female ratio is equal. Perhaps for this reason, relatively little research has examined gender-related risks in BPI course. This article presents data from 186 BPI women and 141 BPI men ascertained as part of the NIMH Genetics Initiative, a multisite collaborative molecular genetic study. Subjects were interviewed using the Diagnostic Interview for Genetic Studies (DIGS). DIGS items included a medical history, and for women, questions concerning psychiatric disorders in relation to childbearing, the menstrual cycle, and menopause. Almost half of BPI women who had been pregnant reported having experienced severe emotional disturbances in relation to childbearing, with close to one-third reporting episode onset during pregnancy. Two-thirds of BPI women reported frequent premenstrual mood disturbances and almost 20 percent of postmenopausal BPI women reported severe emotional disturbances during the menopausal transition. More BPI women than men reported thyroid disorder and migraine headaches. Findings are discussed in relation to gender differences in population and other clinical samples, and in terms of their implications for the development of new treatments and preventive interventions.

   Publication Types:

       * Research Support, U.S. Gov't, P.H.S.


   PMID: 9803748 [PubMed - indexed for MEDLINE]

5: Am J Psychiatry. 1985 Apr;142(4):441-6.    Related Articles, Links

   Fibromyalgia and major affective disorder: a controlled phenomenology and family history study.

   Hudson JI, Hudson MS, Pliner LF, Goldenberg DL, Pope HG Jr.

   Fibromyalgia is a form of nonarticular rheumatism characterized by diffuse musculoskeletal pain. To investigate the relationship between fibromyalgia and major affective disorder, the authors evaluated 31 patients with fibromyalgia and 14 patients with rheumatoid arthritis for rates of current or past major affective disorder and family history of major affective disorder. Both the rate of major affective disorder and the familial prevalence of major affective disorder were significantly higher in the fibromyalgia patients than the rheumatoid arthritis patients. The results suggest that fibromyalgia may be related to major affective disorder.

   Publication Types:

       * Comparative Study
       * Research Support, Non-U.S. Gov't


   PMID: 3856400 [PubMed - indexed for MEDLINE]

6: J Clin Psychiatry. 2004;65 Suppl 15:35-44.    Related Articles, Links
   Click here to read
   Diagnosing and treating comorbid (complicated) bipolar disorder.

   McElroy SL.

   Department of Psychiatry, University of Cincinnati College of Medicine, OH 45267, USA. susan.mcelroy@uc.edu

   Comorbidity is the rule, not the exception, in bipolar disorder. The most common mental disorders that co-occur with bipolar disorder in community studies include anxiety, substance use, and conduct disorders. Disorders of eating, sexual behavior, attention-deficit/hyperactivity, and impulse control, as well as autism spectrum disorders and Tourette's disorder, co-occur with bipolar disorder in clinical samples. The most common general medical comorbidities are migraine, thyroid illness, obesity, type II diabetes, and cardiovascular disease. Bipolarity is a marker for comorbidity, and comorbid disorders, especially multiple conditions occurring when a patient is young, may be a marker for bipolarity. Relatively few controlled clinical studies have examined the treatment of bipolar disorder in the context of comorbid conditions (i.e., complicated or comorbid bipolar disorder). However, the first step in treating any type of complicated bipolar disorder--stabilizing a patient's mood--may be associated with improving the comorbid disorder. Standard mood stabilizers, atypical antipsychotics, and non-antimanic antiepileptic agents are emerging as potentially useful treatments for several of the disorders that frequently co-occur with bipolar disorder, and therefore may be useful treatments for comorbid bipolar disorder.

   Publication Types:

       * Review


   PMID: 15554795 [PubMed - indexed for MEDLINE]

7: Psychiatr Clin North Am. 2003 Sep;26(3):595-620.    Related Articles, Links

   Gender differences in bipolar disorder.

   Arnold LM.

   Department of Psychiatry, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0559, USA. Lesley.Arnold@uc.edu

   The presentation and course of bipolar disorder differs between women and men. The onset of bipolar disorder tends to occur later in women than men, and women more often have a seasonal pattern of the mood disturbance. Women experience depressive episodes, mixed mania, and rapid cycling more often than men. Bipolar II disorder, which is predominated by depressive episodes, also appears to be more common in women than men. Comorbidity of medical and psychiatric disorders is more common in women than men and adversely affects recovery from bipolar disorder more often in women. Comorbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women than men, whereas substance use disorders are more common in men. Although the course and clinical features of bipolar disorder differ between women and men, there is no evidence that gender affects treatment response to mood stabilizers. However, women may be more susceptible to delayed diagnosis and treatment. Treatment of women during pregnancy and lactation is challenging because available mood stabilizers pose potential risks to the developing fetus and infant. Pregnancy neither protects nor exacerbates bipolar disorder, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of bipolar disorder in women, and prophylaxis with mood stabilizers might be needed. Individualized risk/benefit assessments of pregnant and postpartum women with bipolar disorder are required to promote the health of the woman and avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

   Publication Types:

       * Comparative Study
       * Review


   PMID: 14563100 [PubMed - indexed for MEDLINE]

8: Headache. 2003 Oct;43(9):940-9.    Related Articles, Links
   Click here to read
   Prevalence, clinical correlates, and treatment of migraine in bipolar disorder.

   Low NC, Du Fort GG, Cervantes P.

   Mood and Anxiety Disorders Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892, USA.

   OBJECTIVE: To investigate the prevalence, clinical correlates, and treatment of migraine in bipolar disorder. BACKGROUND: The relationship between migraine and mood disorders has been of long-standing interest to researchers and clinicians. Although a strong association has been demonstrated consistently for migraine and major depression, there has been less systematic research on the links between migraine and bipolar disorder. METHODS: A migraine questionnaire (based on International Headache Society criteria) was administered to 108 outpatients with bipolar disorder. Information on the clinical course of bipolar illness was also collected. RESULTS: The overall lifetime prevalence of migraine was 39.8% (43.8% among women and 31.4% among men). In the subgroup of patients with bipolar II disorder, the lifetime prevalence of migraine was 64.7%. The bipolar with migraine group was younger, tended to be more educated, was more likely to be employed or studying, and had fewer psychiatric hospitalizations. Their initial presentation for psychiatric treatment was more often for symptoms of depression, rather than hypomania or mania. They were more likely to have a family history of migraine and psychiatric disorders, and a greater number of affected relatives. They were less likely to use mood stabilizers, and more likely to use atypical antidepressants. Migraine was assessed by a neurologist in only 16% of affected patients. The prevalence of the use of specific antimigraine medications (triptans) was 27.9%. CONCLUSIONS: This study confirms the higher prevalence of migraine among those with bipolar disorder compared to the general population. Migraine in patients with bipolar disorder is underdiagnosed and undertreated. Bipolar disorder with migraine is associated with differences in the clinical course of bipolar disorder, and may represent a subtype of bipolar disorder.

   Publication Types:

       * Comparative Study


   PMID: 14511270 [PubMed - indexed for MEDLINE]

9: World J Biol Psychiatry. 2001 Jul;2(3):149-55.    Related Articles, Links

   Clinical characteristics of patients with major affective disorders and comorbid migraine.

   Fasmer OB, Oedegaard KJ.

   Department of Psychiatry, University of Bergen, Haukeland Hospital, 5021 Bergen, Norway. ole.fasmer@psyk.uib.no

   The present study was undertaken to examine the clinical characteristics of patients with major affective disorders and comorbid migraine. Patients (n = 102) with an index episode of either major depression or mania were interviewed with a semi-structured interview based partly on DSM-IV criteria and partly on Akiskal's criteria for affective temperaments. Compared to the patients without migraine (n = 49), the patients with comorbid migraine (n = 53) had a higher frequency of bipolar II disorder (43% vs. 10%), a lower frequency of bipolar I disorder (11% vs. 33%), an approximately equal frequency of unipolar depressive disorder (45% vs. 57%) and a higher frequency of affective temperaments (45% vs. 22%). The migraine patients also had a greater number of anxiety disorders (3.0 vs. 1.9) and a higher frequency of panic disorder and agoraphobia. Gender distribution, age, age at onset of first affective episode, number of previous episodes and symptoms during depressive episodes were similar in both groups. Based on these findings it is suggested that the presence of migraine may be used to delineate a distinct subgroup of the major affective disorders.

   PMID: 12587198 [PubMed - indexed for MEDLINE]

10: Cephalalgia. 2001 Nov;21(9):894-9.    Related Articles, Links
   Click here to read
   The prevalence of migraine in patients with bipolar and unipolar affective disorders.

   Fasmer OB.

   Department of Psychiatry, University of Bergen, Bergen, Norway. ole.fasmer@psyk.uib.no

   There is a well-known association between migraine and affective disorders, but the information is sparse concerning the prevalence of migraine in subgroups of the affective disorders. The present study was undertaken to investigate the prevalence of migraine in unipolar depressive, bipolar I and bipolar II disorders. Patients with major affective disorders (n = 62), consecutively admitted to an open psychiatric ward, were examined with a semi-structured interview based on DSM-IV diagnostic criteria, combined with separate criteria for affective temperaments. Diagnosis of unipolar and bipolar I disorders followed the DSM-IV criteria, while bipolar II disorder encompassed patients with either discrete hypomanic episodes or a cyclothymic temperament. Migraine was diagnosed according to IHS-criteria. Symptoms of migraine were found to be common in these patients, both in those with unipolar depression (46% prevalence of migraine) and in those with bipolar disorders (44% prevalence). Among the bipolar patients there was, however, a striking difference between the two diagnostic subgroups, with a prevalence of 77% in the bipolar II group compared with 14% in the bipolar I group (P = 0.001). These results support the contention that bipolar I and II are biologically separate disorders and point to the possibility of using the association of bipolar II disorder with migraine to study both the pathophysiology and the genetics of this affective disorder.

   Publication Types:

       * Research Support, Non-U.S. Gov't


   PMID: 11903283 [PubMed - indexed for MEDLINE]